Sleep as a prognostic factor in low back pain: a systematic review of prospective cohort studies and secondary analyses of randomized controlled trials

Sleep problems are common in individuals with low back pain (LBP) and sleep restriction seems to be associated with impaired pain processing. Our objective was to investigate whether sleep is associated with future LBP outcomes (i.e. pain intensity, disability, and recovery) in adults. We conducted a systematic review of prospective cohort studies and secondary analyses of randomized controlled trials (registration-PROSPERO CRD42022370781). In December 2022, we searched the MEDLINE, Embase, CINAHL, and PsycINFO databases. Fourteen studies, totaling 19 170 participants were included. Thirteen studies were rated as having high risk of bias (QUIPS tool). We used vote-counting and meta-analysis approaches to synthesize the data. We found associations between baseline sleep with future pain intensity, recovery, and between changes in sleep with changes in pain intensity, changes in disability, and recovery. We further synthesized outcomes as "overall LBP improvement" outcomes. Baseline poor sleep was moderately associated with non-improvement in LBP in the long-very long term (OR 1.55, 95% CI: 1.39 to 1.73; three studies providing unadjusted effect sizes), and non-improvement in sleep was largely associated with non-improvement in LBP in the short-moderate term (OR 3.45, 95% CI: 2.54 to 4.69; four studies providing unadjusted effect sizes). We found no association between baseline sleep with future disability and overall LBP improvement in the short-moderate term. Therefore, sleep may be a prognostic factor for pain intensity and recovery from LBP. All findings were supported by low to very low-quality evidence. Better-conducted studies are needed to strengthen our certainty about the evidence.

A survey of experts to identify methods to detect problematic studies: Stage 1 of the INSPECT-SR Project

Background

Randomised controlled trials (RCTs) inform healthcare decisions. Unfortunately, some published RCTs contain false data, and some appear to have been entirely fabricated. Systematic reviews are performed to identify and synthesise all RCTs which have been conducted on a given topic. This means that any of these 'problematic studies' are likely to be included, but there are no agreed methods for identifying them. The INSPECT-SR project is developing a tool to identify problematic RCTs in systematic reviews of healthcare-related interventions. The tool will guide the user through a series of 'checks' to determine a study's authenticity. The first objective in the development process is to assemble a comprehensive list of checks to consider for inclusion.

Methods

We assembled an initial list of checks for assessing the authenticity of research studies, with no restriction to RCTs, and categorised these into five domains: Inspecting results in the paper; Inspecting the research team; Inspecting conduct, governance, and transparency; Inspecting text and publication details; Inspecting the individual participant data. We implemented this list as an online survey, and invited people with expertise and experience of assessing potentially problematic studies to participate through professional networks and online forums. Participants were invited to provide feedback on the checks on the list, and were asked to describe any additional checks they knew of, which were not featured in the list.

Results

Extensive feedback on an initial list of 102 checks was provided by 71 participants based in 16 countries across five continents. Fourteen new checks were proposed across the five domains, and suggestions were made to reword checks on the initial list. An updated list of checks was constructed, comprising 116 checks. Many participants expressed a lack of familiarity with statistical checks, and emphasized the importance of feasibility of the tool.

Conclusions

A comprehensive list of trustworthiness checks has been produced. The checks will be evaluated to determine which should be included in the INSPECT-SR tool.

Exercise therapy for treatment of acute non-specific low back pain: a Cochrane systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To assess the effectiveness of exercise for acute non-specific low back pain (LBP) versus our main comparisons: 1) sham treatment, and 2) no treatment at short-term (main follow-up time).

DATA SOURCES AND STUDY SELECTION

A comprehensive search up till November 2021 was conducted in numerous databases for randomised controlled trials (RCTs) on the effectiveness of exercise in adults with acute LBP (< 6 weeks). Studies examining LBP with a specific aetiology were excluded. The primary outcomes were back pain, back-specific functional status and recovery.

DATA EXTRACTION

Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the certainty of the evidence.

DATA SYNTHESIS

We identified 23 RCTs (2674 participants). There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain (mean difference (MD) -0.80, 95% confidence interval (CI) -5.79 to 4.19; 1 study, 299 participants) and on functional status (MD 2.00, 95% CI -2.20 to 6.20; 1 study, 299 participants) in the short term. There is very low-quality evidence which suggests no difference in effect on pain and functional status for exercise vs. no treatment (2 studies; n=157, not pooled due to heterogeneity) at short-term follow-up. Similar results were found for the other follow-up moments. The certainty of the evidence was downgraded because many RCTs had a high risk of bias, were small in size and/or there was substantial heterogeneity.

CONCLUSION

Exercise therapy compared to sham/placebo and no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Understanding how therapeutic exercise prescription changes outcomes important to patients with persistent non-specific low back pain: a realist review protocol

INTRODUCTION

Persistent low back pain (LBP) is the leading cause of disability worldwide, and therapeutic exercise is recommended as a first-line treatment in international guidelines. The effects of exercise on clinical outcomes of pain and physical function are small to moderate, despite broader impacts on cardiovascular systems, biological health, mood, and emotional well-being. Therapeutic exercise prescription is defined as exercise that is prescribed by a clinician for a health-related treatment. It is unknown how therapeutic exercise prescription creates effects on outcomes of importance. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain situations, settings, or populations to create an intended or unintended outcome (O). Our objective is to explore and understand the mechanisms by which therapeutic exercise prescription changes outcomes for people with persistent LBP.

METHODS

We will develop initial programme theories based on preliminary data from a previous systematic review and consensus workshop. These theories will be modified with input from a steering group (experts), a stakeholder group (people with lived experience of exercise for persistent LBP and clinicians), and a scoping search of the published literature. An information specialist will design and undertake an iterative search strategy. These will be used to create CMO configurations, which will be refined and tested using the literature. The realist review will be reported following RAMESES guidance.

DISCUSSION

Realist reviews are uncommon in LBP research to date, yet those offer an opportunity to contrast with traditional methods of randomised controlled trials and systematic reviews and provide additional information regarding the contexts and mechanisms that may trigger certain outcomes. This can aid our understanding of the contextual features that may influence exercise prescription, such as for whom they are most effective, in what setting, how they are implemented and why. This realist synthesis will enhance our understanding of therapeutic exercise prescription to improve adherence and engagement and ultimately will provide clinically relevant recommendations regarding exercise prescription for those with persistent LBP.

SYSTEMATIC REVIEW REGISTRATION

The review has been registered with PROSPERO (CRD42017072023).

Are Exercise Interventions in Clinical Trials for Chronic Low Back Pain Dosed Appropriately to Meet the World Health Organization's Physical Activity Guidelines?

OBJECTIVE

This study aimed to estimate the proportion of exercise interventions tested in clinical trials of people with chronic low back pain (CLBP) that meet the World Health Organization's (WHO) physical activity guidelines.

METHODS

A secondary analysis of the 2021 Cochrane review of exercise therapy for CLBP was performed. Data from each study were extracted by 1 reviewer and were checked by a second reviewer. Data extracted related to the frequency, duration and intensity of each exercise intervention, and the proportion of exercise interventions that met the WHO's physical activity guidelines (aerobic, muscle strengthening, or both) were determined.

RESULTS

The 249 included trials comprised 426 exercise interventions. Few interventions reported an exercise type and dose consistent with the WHO guidelines (aerobic: 1.6%, muscle strengthening: 5.6%, both: 1.6%). Poor reporting of exercise intensity limited our ability to determine whether interventions met the guidelines.

CONCLUSION

Few interventions tested in clinical trials for people with CLBP prescribe an exercise type and dose consistent with the WHO guidelines. Therefore, they do not appear sufficiently dosed to achieve broader health outcomes. Future trials should investigate the effect of WHO guideline-recommended exercise interventions on patient-reported outcomes (pain and disability) as well as health-related outcomes in people with CLBP.

IMPACT

This exploratory analysis showed the lack of exercise interventions in the CLBP literature that meet the WHO's physical activity guidelines. With people in chronic pain groups, such as people with CLBP, being at higher risk for noncommunicable disease, it appears this is a key consideration for exercise practitioners when designing interventions for people with CLBP.

Improving Rehabilitation Research to Optimize Care and Outcomes for People with Chronic Primary Low Back Pain: Methodological and Reporting Recommendations from a WHO Systematic Review Series

Chronic primary low back pain (CPLBP) is a prevalent and disabling condition that often requires rehabilitation interventions to improve function and alleviate pain. This paper aims to advance future research, including systematic reviews and randomized controlled trials (RCTs), on CPLBP management. We provide methodological and reporting recommendations derived from our conducted systematic reviews, offering practical guidance for conducting robust research on the effectiveness of rehabilitation interventions for CPLBP. Our systematic reviews contributed to the development of a WHO clinical guideline for CPLBP. Based on our experience, we have identified methodological issues and recommendations, which are compiled in a comprehensive table and discussed systematically within established frameworks for reporting and critically appraising RCTs. In conclusion, embracing the complexity of CPLBP involves recognizing its multifactorial nature and diverse contexts and planning for varying treatment responses. By embracing this complexity and emphasizing methodological rigor, research in the field can be improved, potentially leading to better care and outcomes for individuals with CPLBP.

Systematic Review Procedures for the World Health Organization (WHO) Evidence Syntheses on Benefits and Harms of Structured and Standardized Education/Advice, Structured Exercise Programs, Transcutaneous Electrical Nerve Stimulation (TENS), and Needling Therapies for the Management of Chronic Low Back Pain in Adults

As commissioned by the WHO, we updated and expanded the scope of four systematic reviews to inform its (in development) clinical practice guideline for the management of CPLBP in adults, including older adults. Methodological details and results of each review are described in the respective articles in this series. In the last article of this series, we discuss methodological considerations, clinical implications and recommendations for future research.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured Exercise Programs for Chronic Primary Low Back Pain in Adults

PURPOSE

Evaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

METHODS

We searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE.

RESULTS

We screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates vs. no intervention, and motor control exercise vs. sham. Improved function was associated with mixed exercise vs. usual care, and Pilates vs. no intervention. Temporary increased minor pain was associated with mixed exercise vs. no intervention, and yoga vs. usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise vs. no intervention probably reduces pain in adults (8 RCTs, SMD = - 0.33, 95% CI - 0.58 to - 0.08) and functional limitations in adults and older adults (8 RCTs, SMD = - 0.31, 95% CI - 0.57 to - 0.05) (moderate certainty evidence).

CONCLUSIONS

With moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.

Protocol for the development of a tool (INSPECT-SR) to identify problematic randomised controlled trials in systematic reviews of health interventions

Introduction

Randomised controlled trials (RCTs) inform healthcare decisions. It is now apparent that some published RCTs contain false data and some appear to have been entirely fabricated. Systematic reviews are performed to identify and synthesise all RCTs that have been conducted on a given topic. While it is usual to assess methodological features of the RCTs in the process of undertaking a systematic review, it is not usual to consider whether the RCTs contain false data. Studies containing false data therefore go unnoticed and contribute to systematic review conclusions. The INSPECT-SR project will develop a tool to assess the trustworthiness of RCTs in systematic reviews of healthcare related interventions.

Methods and analysis

The INSPECT-SR tool will be developed using expert consensus in combination with empirical evidence, over five stages: 1) a survey of experts to assemble a comprehensive list of checks for detecting problematic RCTs, 2) an evaluation of the feasibility and impact of applying the checks to systematic reviews, 3) a Delphi survey to determine which of the checks are supported by expert consensus, culminating in 4) a consensus meeting to select checks to be included in a draft tool and to determine its format, 5) prospective testing of the draft tool in the production of new health systematic reviews, to allow refinement based on user feedback. We anticipate that the INSPECT-SR tool will help researchers to identify problematic studies, and will help patients by protecting them from the influence of false data on their healthcare.

Bias in the measurement of the outcome is associated with effect sizes in randomized clinical trials on exercise therapy for chronic low back pain: a meta-epidemiological study

OBJECTIVES

To explore the relationships between the risk of bias and treatment effect estimates for exercise therapy interventions on pain intensity and physical functioning outcomes in randomized controlled trials (RCTs) involving patients with chronic low back pain.

STUDY DESIGN AND SETTING

A cross-sectional meta-epidemiological study of the 230 RCTs (31,674 participants) in the 2021 'Exercise therapy for chronic low back pain' Cochrane Review were included. Study design characteristics, sample size, prospective trial registration, flowchart information, interventions, and comparisons were extracted. Independent pairs of reviewers assessed the risk of bias using the Cochrane Risk of Bias 2 tool.

RESULTS

The metaregression included 220 (pain intensity) and 203 (physical functioning) effect sizes. Unadjusted and adjusted metaregression models showed no significant associations between the bias domains and pain intensity effect sizes. Only domain 'bias in the measurement of the outcome' was significantly associated with physical functioning (standardized mean difference: -0.40, 95% confidence interval: -0.77 to -0.02) when adjusted for flowchart reported (yes/no), prospective trial registration, sample size, and comparator type.

CONCLUSION

The risk of bias in the measurement of the outcome could lead to slight overestimates of the effect size for physical functioning. Clinicians should consider this when they read and assess RCT results in this field. We encourage metaresearchers to replicate our findings using a consistent approach for evaluating the risk of bias (i.e., the RoB 2 tool) in other musculoskeletal conditions and interventions to investigate their generalizability.

Exercise therapy for treatment of acute non-specific low back pain

BACKGROUND

Low back pain (LBP) is the leading cause of disability globally. It generates considerable direct costs (healthcare) and indirect costs (lost productivity). The many available treatments for LBP include exercise therapy, which is practised extensively worldwide.

OBJECTIVES

To evaluate the benefits and harms of exercise therapy for acute non-specific low back pain in adults compared to sham/placebo treatment or no treatment at short-term, intermediate-term, and long-term follow-up.

SEARCH METHODS

This is an update of a Cochrane Review first published in 2005. We conducted an updated search for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We screened the reference lists of all included studies and relevant systematic reviews published since 2004.

SELECTION CRITERIA

We included RCTs that examined the effects of exercise therapy on non-specific LBP lasting six weeks or less in adults. Major outcomes for this review were pain, functional status, and perceived recovery. Minor outcomes were return to work, health-related quality of life, and adverse events. Our main comparisons were exercise therapy versus sham/placebo treatment and exercise therapy versus no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We evaluated outcomes at short-term follow-up (time point within three months and closest to six weeks after randomisation; main follow-up), intermediate-term follow-up (between nine months and closest to six months), and long-term follow-up (after nine months and closest to 12 months); and we used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 23 studies (13 from the previous review, 10 new studies) that involved 2674 participants and provided data for 2637 participants. Three small studies are awaiting classification, and four eligible studies are ongoing. Included studies were conducted in Europe (N = 9), the Asia-Pacific region (N = 9), and North America (N = 5); and most took place in a primary care setting (N = 12), secondary care setting (N = 6), or both (N = 1). In most studies, the population was middle-aged and included men and women. We judged 10 studies (43%) at low risk of bias with regard to sequence generation and allocation concealment. Blinding is not feasible in exercise therapy, introducing performance and detection bias. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain scores in the short term (mean difference (MD) -0.80, 95% confidence interval (CI) -5.79 to 4.19; 1 study, 299 participants). The absolute difference was 1% less pain (95% CI 4% more to 6% less), and the relative difference was 4% less pain (95% CI 20% more to 28% less). The mean pain score was 20.1 (standard deviation (SD) 21) for the intervention group and 20.9 (SD 23) for the control group. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on functional status scores in the short term (MD 2.00, 95% CI -2.20 to 6.20; 1 study, 299 participants). The absolute difference was 2% worse functional status (95% CI 2% better to 6% worse), and the relative difference was 15% worse (95% CI 17% better to 47% worse). The mean functional status score was 15.3 (SD 19) for the intervention group and 13.3 (SD 18) for the control group. We downgraded the certainty of the evidence for pain and functional status by one level for risk of bias and by two levels for imprecision (only one study with fewer than 400 participants). There is very low-certainty evidence that exercise therapy compared with no treatment has no clinically relevant effect on pain or functional status in the short term (2 studies, 157 participants). We downgraded the certainty of the evidence by two levels for imprecision and by one level for inconsistency. One study associated exercise with small benefits and the other found no differences. The first study was conducted in an occupational healthcare centre, where participants received one exercise therapy session. The other study was conducted in secondary and tertiary care settings, where participants received treatment three times per week for six weeks. We did not pool data from these studies owing to considerable clinical heterogeneity. In two studies, there were no reported adverse events. One study reported adverse events unrelated to exercise therapy. The remaining studies did not report whether any adverse events had occurred. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.

AUTHORS' CONCLUSIONS

Exercise therapy compared to sham/placebo treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Exercise therapy compared to no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. We downgraded the certainty of the evidence to very low for inconsistency, risk of bias concerns, and imprecision (few participants).

Continuous Ultrafiltration Enhances Recovery After Adult Cardiac Surgery With Cardiopulmonary Bypass: A Systematic Review and Meta-analysis

Background

Cardiac surgery with cardiopulmonary bypass is associated with systemic inflammation. Ultrafiltration used throughout the cardiopulmonary bypass time, continuously, is hypothesized to be an immunomodulatory therapy.

Methods

A systematic review and meta-analysis of randomized trials investigating continuous forms of ultrafiltration during adult cardiac surgery (CRD42020219309) was conducted and is reported following PRISMA guidelines. MEDLINE, Embase, CENTRAL, and Scopus were searched on November 3, 2021. The primary endpoint was operative mortality, and secondary outcomes included intensive care unit length of stay (ICU LOS), ventilation time, acute kidney injury or renal failure, and pneumonia. Each study was assessed for risk of bias using the Cochrane Risk-of Bias-Tool for Randomized Trials (RoB2) instrument. Outcomes were analyzed with inverse variance random-effects models and assessed for GRADE quality of evidence.

Results

Twelve randomized trials consisting of 989 adult patients undergoing coronary, valvular, or concomitant cardiac procedures were included. Compared to controls, patients receiving continuous ultrafiltration had no statistical difference in operative mortality; risk ratio of 0.32 (95% confidence interval [CI]: 0.10-1.03; P = 0.06). Reductions occurred in ICU LOS, by 7.01 hours (95% CI: 1.86-12.15; P = 0.008); ventilation time, by 2.11 hours (95% CI: 0.71-3.51; P = 0.003); and incidence of pneumonia, with a risk ratio of 0.33 (95% CI: 0.15-0.75; P = 0.008). There wasno difference in renal injury. The GRADE quality of evidence for these outcomes ranged from very low to low.

Conclusions

Continuous forms of ultrafiltration enhance recovery after adult cardiac surgery by reducing ICU LOS, ventilation time, and incidence of pneumonia. A multicentre randomized trial could confirm and generalize these findings.

Pain catastrophising and kinesiophobia mediate pain and physical function improvements with Pilates exercise in chronic low back pain: a mediation analysis of a randomised controlled trial

QUESTION

How much are the reductions in pain intensity and improvements in physical function from Pilates exercise mediated by changes in pain catastrophising and kinesiophobia?

DESIGN

This was a secondary causal mediation analysis of a four-arm randomised controlled trial testing Pilates exercise dosage (once, twice or thrice per week) against a booklet control.

PARTICIPANTS

Two hundred and fifty-five people with chronic low back pain.

DATA ANALYSIS

All analyses were conducted in R software (version 4.1.2) following a preregistered analysis plan. A directed acyclic graph was constructed to identify potential pre-treatment mediator-outcome confounders. For each mediator model, we estimated the intervention-mediator effect, the mediator-outcome effect, the total natural indirect effect (TNIE), the pure natural direct effect (PNDE), and the total effect (TE).

RESULTS

Pain catastrophising mediated the effect of Pilates exercise compared with control on the outcomes pain intensity (TNIE MD -0.21, 95% CI -0.47 to -0.03) and physical function (TNIE MD -0.64, 95% CI -1.20 to -0.18). Kinesiophobia mediated the effect of Pilates exercise compared with control on the outcomes pain intensity (TNIE MD -0.31, 95% CI -0.68 to -0.02) and physical function (TNIE MD -1.06, 95% CI -1.70 to -0.49). The proportion mediated by each mediator was moderate (21 to 55%).

CONCLUSION

Reductions in pain catastrophising and kinesiophobia partially mediated the pathway to improved pain intensity and physical function when using Pilates exercise for chronic low back pain. These psychological components may be important treatment targets for clinicians and researchers to consider when prescribing exercise for chronic low back pain.

The Maritime SPOR SUPPORT Unit (MSSU) Bridge Process: An Integrated Knowledge Translation Approach to Address Priority Health Issues and Increase Collaborative Research in Nova Scotia, Canada

BACKGROUND

There is evidence of the benefits of integrated knowledge translation (IKT), yet there is limited research outlining the purpose of a knowledge broker (KB) within this approach. The Maritime SPOR SUPPORT Unit (MSSU) acts as a KB to support patient-oriented research across the Maritime provinces in Canada. The "Bridge Process" was developed by the Nova Scotia (NS) site as a strategy that involves work leading up to and following the Bridge Event. The process supports research addressing priority health topics discussed at the event by stakeholder groups. The objectives of this paper were to (1) describe the outputs/outcomes of this IKT approach; and (2) examine the role of the KB.

METHODS

Quantitative data were collected from registration and evaluation surveys. Outputs are described with descriptive statistics. Qualitative data were collected through evaluation surveys and internal documents. Data related to KB tasks were categorized into three domains: (1) Knowledge Manager, (2) Linkage and Exchange Agent, and (3) Capacity Developer.

RESULTS

The Bridge Process was implemented four times. A total of 314 participants including government, health, patient/citizen, community, and research personnel attended the events. We identified 24 priority topics, with 7 led by teams receiving support to complete related projects. Participants reported improved understanding of the research gaps and policy needs and engaged with individuals they would not have otherwise. Although patients/citizens attended each Bridge Event, only 61% of participants who completed an evaluation survey indicated that they were 'actively engaged in group discussion.' The KB's role was identified in all three domains including Knowledge Manager (eg, defining questions), Linkage and Exchange Agent (eg, engaging stakeholders), and Capacity Builder (eg, research interpretation).

CONCLUSION

The MSSU facilitated an IKT approach by acting as a KB throughout the Bridge Process. This deliberative and sequential process served as an effective strategy to increase collaborative health research in the province.

Expectations for Return to Work Predict Return to Work in Workers with Low Back Pain: An Individual Participant Data (IPD) Meta-Analysis

Purpose Low back pain is associated with disability and lost productivity due to inability of workers to return to work. Personal recovery expectation beliefs may be associated with return to work outcomes in those with low back pain at high risk for chronic disability. We aimed to (1) assess whether workers' expectations for return to work, following a low back pain episode, are associated with subsequent return to work; and (2) explore the relationships between return to work expectations and other prognostic factors in their association with work outcomes.Methods We conducted an Individual Participant Data (IPD) meta-analysis using data from five prospective cohort studies identified by a Cochrane prognostic factor review. A one-stage IPD meta-analysis approach was applied. Multi-level mixed effects models were used to determine the unadjusted and adjusted associations between expectations and return to work (logistic regression) and time to return to work (parametric survival models with Weibull distribution).Results The final dataset included 2302 participants. Positive expectations for return to work were associated with return to work at follow-up in both unadjusted (Odds Ratio (OR) 2.95; 95% Confidence Interval (CI) 2.21, 3.95) (n = 2071) and comprehensively adjusted (OR 2.01; 95% CI 1.46, 2.77) (n = 1109) models. Similar findings were identified for shorter length of time to return to work in both unadjusted (HR 2.40; 95% CI 2.09, 2.75) (n = 1156) and minimally adjusted (HR 2.43; 95% CI 2.12, 2.79) (n = 1154) models.Conclusions Results suggest workers with low expectations for return to work are at increased risk for long-term work disability.

Commentary: collaborative systematic review may produce and share high-quality, comparative evidence more efficiently

Systematic reviews are necessary to synthesize available evidence and inform clinical practice and health policy decisions. There has been an explosion of evidence available in many fields; this makes it challenging to keep evidence syntheses up to date and useful. Comparative effectiveness systematic reviews are informative; however, producing these often-large reviews bring intense time and resource demands. This commentary describes the implementation of a systematic review using a collaborative model of evidence synthesis. We are implementing the collaborative review model to update a large Cochrane review investigating the efficacy and comparative effectiveness of the design, delivery, and type of exercise treatment for people with chronic low-back pain. Three key benefits of the collaborative review model for evidence synthesis are (1) team coordination and collaboration, (2) quality control measures, and (3) advanced comparative and other analyses. This new collaborative review model is developed and implemented to produce and share high-quality, comparative evidence more efficiently while building capacity and community within a research field.

Does motor control training improve pain and function in adults with symptomatic lumbar disc herniation? A systematic review and meta-analysis of 861 subjects in 16 trials

OBJECTIVE

To evaluate the effectiveness of motor control training (MCT) compared with other physical therapist-led interventions, minimal/no intervention or surgery in patients with symptomatic lumbar disc herniation (LDH).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight databases and the ClinicalTrials.gov were searched from inception to April 2021.

ELIGIBILITY CRITERIA

We included clinical trial studies with concurrent comparison groups which examined the effectiveness of MCT in patients with symptomatic LDH. Primary outcomes were pain intensity and functional status which were expressed as mean difference (MD) and standardised mean difference (SMD), respectively.

RESULTS

We screened 6695 articles, of which 16 clinical trials (861 participants) were eligible. Fourteen studies were judged to have high risk of bias and two studies had some risk of bias. In patients who did not undergo surgery, MCT resulted in clinically meaningful pain reduction compared with other physical therapist-led interventions (ie, transcutaneous electrical nerve stimulation (TENS)) at short-term (MD -28.85, -40.04 to -17.66, n=69, studies=2). However, the robustness of the finding was poor. For functional status, a large and statistically significant treatment effect was found in favour of MCT compared with traditional/classic general exercises at long-term (SMD -0.83 to -1.35 to -0.31, n=63, studies=1) and other physical therapist-led interventions (ie, TENS) at short-term (SMD -1.43 to -2.41 to -0.46, n=69, studies=2). No studies compared MCT with surgery. In patients who had undergone surgery, large SMDs were seen. In favour of MCT compared with traditional/classic general exercises (SMD -0.95 to -1.32 to -0.58, n=124, studies=3), other physical therapist-led interventions (ie, conventional treatments; SMD -2.30 to -2.96 to -1.64, n=60, studies=1), and minimal intervention (SMD -1.34 to -1.87 to -0.81, n=68, studies=2) for functional improvement at short-term. The overall certainty of evidence was very low to low.

CONCLUSION

At short-term, MCT improved pain and function compared with TENS in patients with symptomatic LDH who did not have surgery. MCT improved function compared with traditional/classic general exercises at long-term in patients who had undergone surgery. However, the results should be interpreted with caution because of the high risk of bias in the majority of studies.

PROSPERO REGISTRATION NUMBER

CRD42016038166.

Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis

QUESTION

What are the effects of specific types of exercise treatments on pain intensity and functional limitation outcomes for adults with chronic low back pain?

DESIGN

Systematic review with network meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults with non-specific low back pain for ≥ 12 weeks.

INTERVENTION

Exercise treatments prescribed or planned by a health professional that involved conducting specific activities, postures and/or movements with a goal to improve low back pain outcomes.

OUTCOME MEASURES

Pain intensity (eg, visual analogue scale or numerical rating scale) and back-related functional limitations (eg, Roland Morris Disability Questionnaire or Oswestry Disability Index), each standardised to range from 0 to 100.

RESULTS

This review included 217 randomised controlled trials with 20,969 participants and 507 treatment groups. Most exercise types were more effective than minimal treatment for pain and functional limitation outcomes. Network meta-analysis results were compatible with moderate to clinically important treatment effects for Pilates, McKenzie therapy, and functional restoration (pain only) and flexibility exercises (function only) compared with minimal treatment, other effective treatments and other exercise types. The estimated mean differences for these exercise types compared with minimal treatment ranged from -15 to -19 for pain and from -10 to -12 for functional limitation.

CONCLUSION

This review found evidence that Pilates, McKenzie therapy and functional restoration were more effective than other types of exercise treatment for reducing pain intensity and functional limitations. Nevertheless, people with chronic low back pain should be encouraged to perform the exercise that they enjoy to promote adherence.

REGISTRATION

DOI:10.1002/14651858.CD009790.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Health Care Provider Utilization of Prescription Monitoring Programs: A Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize the literature on the proportion of health care providers who access and use prescription monitoring program data in their practice, as well as associated barriers to the use of such data.

DESIGN

We performed a systematic review using a standard systematic review method with meta-analysis and qualitative meta-summary. We included full-published peer-reviewed reports of study data, as well as theses and dissertations.

METHODS

We identified relevant quantitative and qualitative studies. We synthesized outcomes related to prescription monitoring program data use (i.e., ever used, frequency of use). We pooled the proportion of health care providers who had ever used prescription monitoring program data by using random effects models, and we used meta-summary methodology to identify prescription monitoring program use barriers.

RESULTS

Fifty-three studies were included in our review, all from the United States. Of these, 46 reported on prescription monitoring program use and 32 reported on barriers. The pooled proportion of health care providers who had ever used prescription monitoring program data was 0.57 (95% confidence interval: 0.48-0.66). Common barriers to prescription monitoring program data use included time constraints and administrative burdens, low perceived value of prescription monitoring program data, and problems with prescription monitoring program system usability.

CONCLUSIONS

Our study found that health care providers underutilize prescription monitoring program data and that many barriers exist to prescription monitoring program data use.

Search methods for prognostic factor systematic reviews: a methodologic investigation

Objective

This study retroactively investigated the search used in a 2019 review by Hayden et al., one of the first systematic reviews of prognostic factors that was published in the Cochrane Library. The review was designed to address recognized weaknesses in reviews of prognosis by using multiple supplementary search methods in addition to traditional electronic database searching.

Methods

The authors used four approaches to comprehensively assess aspects of systematic review literature searching for prognostic factor studies: (1) comparison of search recall of broad versus focused electronic search strategies, (2) linking of search methods of origin for eligible studies, (3) analysis of impact of supplementary search methods on meta-analysis conclusions, and (4) analysis of prognosis filter performance.

Results

The review's focused electronic search strategy resulted in a 91% reduction in recall, compared to a broader version. Had the team relied on the focused search strategy without using supplementary search methods, they would have missed 23 of 58 eligible studies that were indexed in MEDLINE; additionally, the number of included studies in 2 of the review's primary outcome meta-analyses would have changed. Using a broader strategy without supplementary searches would still have missed 5 studies. The prognosis filter used in the review demonstrated the highest sensitivity of any of the filters tested.

Conclusions

Our study results support recommendations for supplementary search methods made by prominent systematic review methodologists. Leaving out any supplemental search methods would have resulted in missed studies, and these omissions would not have been prevented by using a broader search strategy or any of the other prognosis filters tested.

A Systematic Review of the Prospective Relationship Between Bullying Victimization and Pain

Objective

This systematic review synthesized evidence about the relationship between childhood bullying victimization and chronic pain, with a focus on the temporal nature of the relationship and moderating factors, such as the type and intensity of victimization.

Method

We included prospective cohort studies that examined the relationship between childhood bullying victimization and pain measured at least three months later. We conducted electronic searches of Medline, EMBASE, PsycINFO, and CINAHL up to June 30, 2019. Standard methodological procedures consistent with Cochrane reviews of prognosis studies were used (PROSPERO record ID 133146).

Results

We included four longitudinal studies (6275 participants) in this review. The mean age of participants at baseline ranged from 10 to 14 years and the follow-up periods ranged from 6 months to 12 years. Two of the four studies were judged as having high risk of bias. Meta-analysis of results from four studies revealed increased risk of pain among victimized compared to non-victimized youth (adjusted OR [95% CI] = 1.45 [1.06-1.97], but the effect size was small and not clinically important. Only one study examined the inverse association (ie, from pain to victimization), and there was not enough evidence to conduct a meaningful analysis of the proposed moderators.

Conclusions

Study findings were limited by few prospective studies. Meta-analytic findings suggested that victimization may incur some risk for later pain, although the evidence was judged to be very low quality. High-quality studies that measure and report the nuances of bullying victimization are needed to test the proposed moderator models.

Meta-epidemiological study of publication integrity, and quality of conduct and reporting of randomized trials included in a systematic review of low back pain

OBJECTIVE

To comprehensively describe the quality of conduct, reporting, and publication integrity characteristics for all trials included in a large Cochrane review, comparing those published by presumed predatory publishers with those published by nonpredatory publishers.

DESIGN

Cross-sectional meta-epidemiological study.

STUDY SELECTION

Two hundred seventy-nine studies (25,704 participants) eligible for the recent update of the "Exercise therapy for chronic low back pain" Cochrane review were included.

DATA EXTRACTION

Study and manuscript characteristics, including predatory publication status and other quality and integrity characteristics were extracted along with treatment effect.

RESULTS

Nine percent of trials included were in presumed predatory publications; 12% in the period since 2010. We found frequency of other concerning characteristics to range from low (eg, plagiarism, 5%) to common (eg, lack of evidence of trial registration or protocol publication [75%]; insufficient sample size [84%]) in included studies. Studies published by presumed predatory publishers consistently had inferior conduct, reporting and publication integrity characteristics. Presumed predatory publication was associated with missing conflict of interest statement (OR 7.6, 95% CI 3.0-19.1), inadequate follow-up duration (OR 11.2, 95% CI 3.7-33.7), incomplete study methods (OR 12.1, 95% CI 2.8-52.2) and baseline reporting (OR 4.3, 95% CI 1.6-11.7), and high risk of bias (OR 2.7, 95% CI 1.2-6.3). All (100%) presumed predatory publications were missing trial registrations (vs. 72%) and had inadequate sample sizes (vs. 82%). Trials published in presumed predatory journals did not appear to have inflated effect sizes.

CONCLUSIONS

Predatory publishers pose a distinct challenge to the consumption and synthesis of randomized controlled trials. More work is needed in other clinical areas to understand the potential impact of randomized controlled trials published in predatory publications, and as a result, the potential impact on evidence from systematic reviews that include these studies.

Moderators of the Effect of Spinal Manipulative Therapy on Pain Relief and Function in Patients with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

STUDY DESIGN

Individual participant data (IPD) meta-analysis.

OBJECTIVE

The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP.

SUMMARY OF BACKGROUND

The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies.

METHODS

IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months).

RESULTS

We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data.

CONCLUSION

We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.

Treatment targets of exercise for persistent non-specific low back pain: a consensus study

OBJECTIVES

Despite several hundred previous randomised controlled trials (RCTs), the key treatment targets of exercise for persistent non-specific low back pain (NSLBP) remain unclear. This study aimed to generate consensus about the key treatment targets of exercise interventions for patients with NSLBP.

DESIGN

Consensus was generated using modified nominal group technique in two, sequential, workshops. The results of a previous systematic review informed the first, national, workshop idea generation and the results of this workshop informed the second, international, workshop. The authors generated a starting list of 30 treatment targets from the systematic review. A pre-specified consensus threshold of 75% was used in the voting stage.

PARTICIPANTS

Workshop participants included people with experience of using exercise to manage their persistent NSLBP, clinicians who prescribe exercise for persistent NSLBP, and researchers who design and evaluate exercise interventions in RCTs. All participants generated, voted and ranked the treatment targets in each workshop using an online platform.

RESULTS

A total of 39 participants contributed to the consensus (15 in the national workshop and 24 in the international workshop), comprising two people with NSLBP, six clinicians and 31 researchers/clinicians. A total of 40 exercise treatment targets were generated, and 25 were retained after voting and ranking. The prioritised targets of exercise for persistent NSLBP were: improving function, improving quality of life, reducing pain, meeting patient-specific goals and reducing fear of movement.

CONCLUSIONS

Future RCTs of exercise should specify the targets of their exercise intervention and consider assessing these treatment targets as well as including mediation analyses.

The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis

BACKGROUND

A 2019 review concluded that spinal manipulative therapy (SMT) results in similar benefit compared to other interventions for chronic low back pain (LBP). Compared to traditional aggregate analyses individual participant data (IPD) meta-analyses allows for a more precise estimate of the treatment effect.

PURPOSE

To assess the effect of SMT on pain and function for chronic LBP in a IPD meta-analysis.

DATA SOURCES

Electronic databases from 2000 until April 2016, and reference lists of eligible trials and related reviews.

STUDY SELECTION

Randomized controlled trials (RCT) examining the effect of SMT in adults with chronic LBP compared to any comparator.

DATA EXTRACTION AND DATA SYNTHESIS

We contacted authors from eligible trials. Two review authors independently conducted the study selection and risk of bias. We used GRADE to assess the quality of the evidence. A one-stage mixed model analysis was conducted. Negative point estimates of the mean difference (MD) or standardized mean difference (SMD) favors SMT.

RESULTS

Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants) and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings.

LIMITATIONS

Only 50% of the eligible trials were included.

CONCLUSIONS

Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP. Systematic Review Registration Number PROSPERO CRD42015025714.

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials

Background

Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise.

Methods

In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers.

Results

We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) −10.7 (−14.1 to –7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) −10.2 (−13.2 to –7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers—these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics.

Conclusions

This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups.

Protocol publication

https://doi.org/10.1186/2046-4053-1-64

Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review

BACKGROUND

Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.

OBJECTIVES

To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.

SEARCH METHODS

The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.

SELECTION CRITERIA

We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.

MAIN RESULTS

We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.

AUTHORS' CONCLUSIONS

We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.

The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review

Background

In order to address the opioid crisis in North America, many regions have adopted preventative strategies, such as prescription drug monitoring programs (PDMPs). PDMPs aim to increase patient safety by certifying that opioids are prescribed in appropriate quantities. We aimed to synthesize the literature on changes in opioid-related harms and consequences, an important measure of PDMP effectiveness.

Methods

We completed a systematic review. We conducted a narrative synthesis of opioid-related harms and consequences from PDMP implementation. Outcomes were grouped into categories by theme: opioid dependence, opioid-related care outcomes, opioid-related adverse events, and opioid-related legal and crime outcomes.

Results

We included a total of 22 studies (49 PDMPs) in our review. Two studies reported on illicit and problematic use but found no significant associations with PDMP status. Eight studies examined the association between PDMP status and opioid-related care outcomes, of which two found that treatment admissions for prescriptions opioids were lower in states with PDMP programs (p < 0.05). Of the thirteen studies that reported on opioid-related adverse events, two found significant (p < 0.001 and p < 0.05) but conflicting results with one finding a decrease in opioid-related overdose deaths after PDMP implementation and the other an increase. Lastly, two studies found no statistically significant association between PDMP status and opioid-related legal and crime outcomes (crime rates, identification of potential dealers, and diversion).

Conclusion

Our study found limited evidence to support overall associations between PDMPs and reductions in opioid-related consequences. However, this should not detract from the value of PDMPs’ larger role of improving opioid prescribing.

Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

BACKGROUND

Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP.

METHODS

We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach.

RESULTS

Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies).

CONCLUSIONS

Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption.

REGISTRATION

PROSPERO 2017, CRD42017070703.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study

BACKGROUND

At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings.

METHODS

The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients.

DISCUSSION

This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

Development of a clinical decision support tool for diagnostic imaging use in patients with low back pain: a study protocol

BACKGROUND

Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available.

METHODS

This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users.

DISCUSSION

Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.

Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review synthesizing the evidence for the effectiveness of the Wheelchair Skills Training Program (WSTP).

DATA SOURCES

We searched PubMed, the Cochrane Library, CINAHL and Embase databases, as well as grey literature, up to 10 October 2017.

STUDY SELECTION

Randomized controlled trials (RCTs) assessing the effectiveness of the WSTP.

DATA EXTRACTION

Two independent reviewers screened articles and extracted data. Methodological quality was assessed using Cochrane's Risk of Bias Tool.

DATA SYNTHESIS

Meta-analyses (including sub-group analyses) were conducted for the Wheelchair Skills Test (WST) and WST Questionnaire (WST-Q) total capacity scores. We qualitatively assessed retention, WST/WST-Q subtotal and individual-skill capacity scores and other identified outcomes. The quality of evidence was determined using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Thirteen articles (581 participants) were included for analysis. The level of evidence was of moderate quality. The WSTP increased the post-training WST/WST-Q total capacity scores by 14.0% (95% CI: 7.4, 20.8; p < .0001) compared to no treatment, standard care or educational controls, a relative increase over baseline of 21.2%. Subgroup analyses showed that training was more effective for new wheelchair users. Retention of training effects was suggested by the absence of significant declines between tests post-training and at follow-up. The WSTP was found to have positive effects on some other outcomes. No serious adverse events were reported.

CONCLUSIONS

There is moderate quality evidence that the WSTP is a safe intervention that has a clinically meaningful effect on WST/WST-Q capacity scores and some other outcomes. Implications for rehabilitation A systematic review and meta-analysis of 13 randomized controlled trials on a total of 581 participants, using the Wheelchair Skills Training Program (WSTP) as the intervention, found that the WSTP increased Wheelchair Skills Test (WST) and WST Questionnaire (WST-Q) total capacity scores by 21.2% relative to baseline. Subgroup analyses showed that training was more effective for new wheelchair users. The WSTP was found to have positive effects on some other outcomes and no serious adverse events were reported. The WSTP warrants cautious implementation in clinical and educational settings.

Cost effectiveness of guided Internet-based interventions for depression in comparison with control conditions: An individual-participant data meta-analysis

BACKGROUND

There is limited evidence on the cost effectiveness of Internet-based treatments for depression. The aim was to evaluate the cost effectiveness of guided Internet-based interventions for depression compared to controls.

METHODS

Individual-participant data from five randomized controlled trials (RCT), including 1,426 participants, were combined. Cost-effectiveness analyses were conducted at 8 weeks, 6 months, and 12 months follow-up.

RESULTS

The guided Internet-based interventions were more costly than the controls, but not statistically significant (12 months mean difference = €406, 95% CI: - 611 to 1,444). The mean differences in clinical effects were not statistically significant (12 months mean difference = 1.75, 95% CI: - .09 to 3.60 in Center for Epidemiologic Studies Depression Scale [CES-D] score, .06, 95% CI: - .02 to .13 in response rate, and .00, 95% CI: - .03 to .03 in quality-adjusted life-years [QALYs]). Cost-effectiveness acceptability curves indicated that high investments are needed to reach an acceptable probability that the intervention is cost effective compared to control for CES-D and response to treatment (e.g., at 12-month follow-up the probability of being cost effective was .95 at a ceiling ratio of 2,000 €/point of improvement in CES-D score). For QALYs, the intervention's probability of being cost effective compared to control was low at the commonly accepted willingness-to-pay threshold (e.g., at 12-month follow-up the probability was .29 and. 31 at a ceiling ratio of 24,000 and 35,000 €/QALY, respectively).

CONCLUSIONS

Based on the present findings, guided Internet-based interventions for depression are not considered cost effective compared to controls. However, only a minority of RCTs investigating the clinical effectiveness of guided Internet-based interventions also assessed cost effectiveness and were included in this individual-participant data meta-analysis.

Research priorities of the Canadian chiropractic profession: a consensus study using a modified Delphi technique

Background

Research funds are limited and a healthcare profession that supports research activity should establish research priority areas. The study objective was to identify research priority areas for the Canadian chiropractic profession, and for stakeholders in the chiropractic profession to rank these in order of importance.

Methods

We conducted a modified Delphi consensus study between August 2015 and May 2017 to determine the views of Canadian chiropractic organisations (e.g. Canadian Chiropractic Association; provincial associations) and stakeholder groups (e.g. chiropractic educational institutions; researchers). Participants completed three online Delphi survey rounds. In Round 1, participants suggested research areas within four broad research themes: 1) Basic science; 2) Clinical; 3) Health services; and 4) Population health. In Round 2, researchers created sub-themes by categorising the areas suggested in Round 1, and participants judged the importance of the research sub-themes. We defined consensus as at least 70% of participants agreeing that a research area was "essential" or "very important". In Round 3, results from Round 2 were presented to the participants to re-evaluate the importance of sub-themes. Finally, participants completed an online pairwise ranking activity to determine the rank order of the list of important research sub-themes.

Results

Fifty-seven participants, of 85 people invited, completed Round 1 (response rate 67%). Fifty-six participants completed Round 2, 55 completed Round 3, and 53 completed the ranking activity. After three Delphi rounds and the pairwise ranking activity was completed, the ranked list of research sub-themes considered important were: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services; 4) Effects of chiropractic care; 5) Safety/side effects of chiropractic care; 6) Chiropractic care for older adults; 7) Neurophysiological mechanisms and effects of spinal manipulative therapy; 8) General mechanisms and effects of spinal manipulative therapy.

Conclusions

This project identified research priority areas for the Canadian chiropractic profession. The top three priority areas were all in the area of health services research: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services.

A scoping review on the study of siblings in pediatric pain

Background: Sibling relationships are longstanding across an individual’s life and are influential in children’s development. The study of siblings in pediatric pain is, although in early stages, a growing field.

Aims: This scoping review sought to summarize and map the type of research available examining siblings and pediatric pain to identify gaps and directions for future research.

Methods: Studies were identified based on a search of PubMed, CINAHL, PsycInfo, Embase, and Web of Science (up to November 2016). We extracted data about study methods, the sample, outcome assessment, and the influence/relationships investigated.

Results: Thirty-five studies were included. Most studies used quantitative methods (n = 28), and participants typically included children (i.e., aged 6–12; n = 24) and adolescents (i.e., aged 13–18; n = 18). The majority of studies examined siblings in the context of chronic and disease-related pain (n = 30). Though quantitative studies primarily focused on the genetic influence of pain conditions (n = 18), qualitative and mixed-methods studies typically focused on exploring the impact of siblings with and without pain on one another (n = 2) and the impact of pain on the broader dyadic relationship/functioning (n = 4).

Conclusions: Sibling research in pediatric pain has been primarily focused on the biological/physical components of pain, using quantitative approaches. Conducting more studies using qualitative or mixed-methods designs, incorporating multiple assessment measures (e.g., observational, self-report) and multiple perspectives (e.g., siblings, health professionals), may provide an opportunity to gain richer and more comprehensive information regarding the experience of siblings.

Informing a research agenda for the Canadian chiropractic profession

Our research group recently published a Delphi study that identified Canadian chiropractic profession research priority areas. At the same time, the Canadian Chiropractic Research Foundation (CCRF) was developing their own research priority areas. In this commentary, we discuss the results of the Delphi study, compare and contrast these results to the research priorities of the CCRF, and report new data from a survey about where members of the chiropractic profession think that available research funding should be spent. Ongoing dialogue is needed with all Canadian chiropractic stakeholders to turn these research priorities into action.

Who will have Sustainable Employment After a Back Injury? The Development of a Clinical Prediction Model in a Cohort of Injured Workers

Purpose Our objective was to develop a clinical prediction model to identify workers with sustainable employment following an episode of work-related low back pain (LBP). Methods We used data from a cohort study of injured workers with incident LBP claims in the USA to predict employment patterns 1 and 6 months following a workers' compensation claim. We developed three sequential models to determine the contribution of three domains of variables: (1) basic demographic/clinical variables; (2) health-related variables; and (3) work-related factors. Multivariable logistic regression was used to develop the predictive models. We constructed receiver operator curves and used the c-index to measure predictive accuracy. Results Seventy-nine percent and 77 % of workers had sustainable employment at 1 and 6 months, respectively. Sustainable employment at 1 month was predicted by initial back pain intensity, mental health-related quality of life, claim litigation and employer type (c-index = 0.77). At 6 months, sustainable employment was predicted by physical and mental health-related quality of life, claim litigation and employer type (c-index = 0.77). Adding health-related and work-related variables to models improved predictive accuracy by 8.5 and 10 % at 1 and 6 months respectively. Conclusion We developed clinically-relevant models to predict sustainable employment in injured workers who made a workers' compensation claim for LBP. Inquiring about back pain intensity, physical and mental health-related quality of life, claim litigation and employer type may be beneficial in developing programs of care. Our models need to be validated in other populations.

Protocol: a systematic review of studies developing and/or evaluating search strategies to identify prognosis studies

BACKGROUND

Prognosis research is on the rise, its importance recognised because chronic health conditions and diseases are increasingly common and costly. Prognosis systematic reviews are needed to collate and synthesise these research findings, especially to help inform effective clinical decision-making and healthcare policy. A detailed, comprehensive search strategy is central to any systematic review. However, within prognosis research, this is challenging due to poor reporting and inconsistent use of available indexing terms in electronic databases. Whilst many published search filters exist for finding clinical trials, this is not the case for prognosis studies. This systematic review aims to identify and compare existing methodological filters developed and evaluated to identify prognosis studies of any of the three main types: overall prognosis, prognostic factors, and prognostic [risk prediction] models.

METHODS

Primary studies reporting the development and/or evaluation of methodological search filters to retrieve any type of prognosis study will be included in this systematic review. Multiple electronic bibliographic databases will be searched, grey literature will be sought from relevant organisations and websites, experts will be contacted, and citation tracking of key papers and reference list checking of all included papers will be undertaken. Titles will be screened by one person, and abstracts and full articles will be reviewed for inclusion independently by two reviewers. Data extraction and quality assessment will also be undertaken independently by two reviewers with disagreements resolved by discussion or by a third reviewer if necessary. Filters' characteristics and performance metrics reported in the included studies will be extracted and tabulated. To enable comparisons, filters will be grouped according to database, platform, type of prognosis study, and type of filter for which it was intended.

DISCUSSION

This systematic review will identify all existing validated prognosis search filters and synthesise evidence about their applicability and performance. These findings will identify if current filters provide a proficient means of searching electronic bibliographic databases or if further prognosis filters are needed and can feasibly be developed for systematic searches of prognosis studies.

Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability.

CONCLUSION

Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.

Current management practices for patients presenting with low back pain to a large emergency department in Canada

Background

Low back pain (LBP) is one of the leading causes of disability. Presentations to the emergency department (ED) are common and consume significant healthcare resources. However, treatment of patients with LBP is variable and highly physician dependent. Our study objective was to describe the demographic and clinical characteristics of patients presenting to the ED with LBP, the diagnostic strategies employed by ED physicians, and the subsequent management.

Methods

We conducted a retrospective study using clinical and electronic health data at the Queen Elizabeth II Health Science Center’s Charles V. Keating Emergency and Trauma Centre. We selected a simple random sample of 325 adult participants who presented to the ED with non-urgent LBP over a six-year period. Data for all participants, including demographic characteristics, diagnostic testing, and interventions received, was retrieved from the Emergency Department Information System database and from patient charts.

Results

Participants had a median age of 43 years and 55% were female. The majority (92.9%) were acute presentations of LBP (less than 4 weeks of duration), with an assigned Canadian Triage Acuity Scale score of 3-4 (92.4%). A range of pain intensity scores were reported, mostly without associated neurological symptoms (81%) or sciatica (68%). At triage, pain score was most commonly reported as moderate intensity (57.6%), followed by severe (32.6%) and mild (9.9%). Documentation of pain rating during assessment was similar (moderate 68.6%; severe 25.9%; mild 5.6%). Laboratory investigations were conducted on 22.5% of participants and 30% received an imaging study. Medications were delivered to 59.4% of participants during their stay in the ED. Of the medications administered, ibuprofen (28.3%), hydromorphone (24.9%), and acetaminophen (21.5%) were the most frequent. Almost all (94%) had a record of having a primary care provider in EDIS and referrals back to the participant’s family physician were recorded for 41.2% of non-urgent LBP encounters.

Conclusions

We presented a complete description of patient characteristics, LBP descriptors, and health service use for a random sample of non-urgent LBP patients presenting to the ED. This has allowed for a better understanding of patients who seek care in the ED for their non-urgent LBP.